First steps

• 12-lead ECG within 10 min of arrival
• ABCDE, IV access × 2, monitor, defib pads
• Aspirin 300 mg chewed
• P2Y12 loading (ticagrelor 180 or prasugrel 60 mg)
• Analgesia: morphine 2-5 mg IV, GTN sublingual/IV if no RV MI

Key investigations

• 12-lead ECG (posterior + right-sided if inferior)
• hs-troponin serial
• CBC, U&E, glucose, coag, group & save
• Portable CXR, bedside echo

Differentials

• Aortic dissection (CT angio if suspected)
• PE with RV strain
• Myocarditis/pericarditis
• Oesophageal rupture
• Tension pneumothorax

Initial management

• Primary PCI ≤120 min from FMC is preferred
• Fibrinolysis (tenecteplase weight-based bolus) if PCI unavailable ≤120 min and no contraindications
• Anticoag: heparin 60 U/kg (max 4000) or bivalirudin for PCI; enoxaparin bolus for lysis
• IABP/Impella for cardiogenic shock
• Post-PCI: DAPT 12 months, statin 80 mg, β-blocker, ACEi if EF <40

Referral

• Cath lab activation
• CT surgery if mechanical complication
• Cardiac rehab post-discharge

Patient counseling

• Time = muscle — every 30 min delay increases mortality
• Explain dual antiplatelet importance (stent thrombosis risk)
• Cardiac rehab referral improves outcomes

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